Innovative research through education, clinical and health services

The future of primary care will largely be shaped by the discoveries made in research and its application within clinical settings. DFCM is in a unique position to produce and disseminate new evidence about primary care practices that can be beneficial to health communities around the world.

DFCM has made concerted efforts to invest in its research enterprise with the launch of the University of Toronto Practice-Based Research Network (UTOPIAN). Its purpose is to strengthen interest and engagement in research within the faculty, leading to important discoveries and influencing health-care policies.

To influence research in Canada that will impact primary care, DFCM has also made a considerable effort in helping faculty to build skills required to effectively conduct research and made investments in providing the mentorship necessary to sustain and grow these efforts considerably.

Recent research stemming from data collected from UTOPIAN has shown important developments in health care. The stories below speak about the endeavours that the DFCM has striven to accomplish to meet its goals as outlined in the strategic plan.

“One of our major requirements is that UTOPIAN projects contribute to the growth and development of primary care research at DFCM and beyond, and we are seeing that happen

—Dr. Michelle Greiver

Dr. Frank Sullivan, former director of UTOPIAN

UTOPIAN: Supporting Practice-Based Research

When Dr. Navsheer Toor and her colleagues at Southlake Regional Health Centre in Newmarket, Ontario, wanted to broaden their program of home visits, Toor turned to UTOPIAN, the University of Toronto Practice-Based Research Network, for help in creating a research project to inform the program’s redesign.

"Our aim was to reduce the burden on emergency rooms by providing home visits to people who can’t always get to our clinics for treatment,” Toor said. “UTOPIAN provided assistance to get things going and helped us navigate the research world.”

UTOPIAN is available at all 14 University of Toronto teaching sites in the Greater Toronto Area and beyond and includes approximately 1,400 family physicians looking after more than one million patients. Patient data is retrieved every three months from the Electronic Medical Records of an increasing number of practices; the data are anonymized and stored safely. UTOPIAN holds anonymized data for about half a million patients, making it one of the largest single research databases in Canada.

“UTOPIAN provides support to make it more feasible to do research in family practice and to do more research where much of the care in the community actually happens – with family physicians,” said Dr. Michelle Greiver, the network’s acting director and an associate professor with the University of Toronto’s Department of Family and Community Medicine (DFCM).

During its first three years of existence, the network has grown rapidly, Greiver said, supporting an increasing number of research projects annually and disbursing a growing amount of funding. In 2014-15, $83,000 was awarded to seven projects; last year, 19 projects were underway and this year, UTOPIAN is supporting 25 research projects. The projects are reviewed by UTOPIAN’s Scientific Advisory Committee (SAC), which meets every two months. Researchers doing projects approved by UTOPIAN’s SAC can have access to support services, such as research mentorship; biostatistical services; and assistance with project management.

One of the largest projects that UTOPIAN is collaborating with is Diabetes Action Canada (DAC). DAC is a Canadian Institutes for Health Research initiative with $35 million in funding. UTOPIAN is a significant partner in DAC’s effort to develop a national diabetes data platform, which will include EMR (emergency medical records) data from primary care networks in several provinces, as well as patient-reported data obtained from smartphones and other devices. This will contribute to a number of activities, including research, with the aim of transforming the health outcomes of people living with diabetes.

For family physicians wishing to embark on a research project, UTOPIAN staff can help with the process. Once a year, UTOPIAN offers a two-day Idea to Proposal (I2P) course explaining the process from start to finish and highlighting the ways the network can assist. Toor said attending the Idea to Proposal workshop gave her the background to develop her research question and an understanding of the help that was available to carry out the project.

Dr. Rajesh Girdhari, a family physician and addictions specialist at St. Michael’s Hospital in Toronto, also attended the I2P course.

“The course was useful,” Girdhari said. “It dealt with different aspects of the research process, including writing a grant proposal, establishing a research budget and framing research questions and objectives in a way that excites interest in others.”

As part of the course, Girdhari wrote a grant proposal for a survey to study how DFCM physicians use email in their practices. The proposal was funded, and he and three colleagues are in the process of refining the survey questionnaire with plans to disseminate it by email later this year.

Approximately 1,400 family physicians with ties to DFCM will receive the questionnaire; it will be created using Qualtrics software that DFCM offers to members. Girdhari and his colleagues are also taking advantage of the consultations with experienced researchers at DFCM to help determine the steps necessary to go from questionnaire design to dissemination, data collection and analysis.

“We don’t have a lot of data at the provincial level about how family physicians use email in their practices, although the annual Commonwealth survey indicates that about 15 per cent of family physicians in the participating countries use it,” Girdhari said. “Anecdotally, we feel the number is much higher.”

“We want to know what Ontario physicians are doing to make email work for them as a tool in their practices. The survey information will be useful in contributing to practical policies or guidelines and it will help us get insights into best practices based on physician feedback.”

Griever is delighted to see involvement with UTOPIAN growing.

“One of our major requirements is that UTOPIAN projects contribute to the growth and development of primary care research at DFCM and beyond, and we are seeing that happen,” she said. “We are very grateful for the commitment of our Department’s leadership and for so many colleagues at DFCM that have made UTOPIAN a reality.”

“One of our major requirements is that UTOPIAN projects contribute to the growth and development of primary care research at DFCM and beyond, and we are seeing that happen,” she said. “We are very grateful for the commitment of our Department’s leadership and for so many colleagues at DFCM that have made UTOPIAN a reality.”

Validating an Algorithm to Identify People Living with Hepatitis C Using Electronic Medical Record Data and Assessing the Quality of Primary Care Provided

Individualizing Glycemia Control in Canadians to Meet Guideline Recommendations

People living with diabetes may not all meet their individual targets for their blood sugar levels according to a study published in BMJ Open Diabetes Research and Care journal, featuring researchers at the University of Toronto’s Department of Family and Community Medicine.

The study showed that young people living with diabetes were more likely to have poor to moderately controlled blood sugar rather than tightly controlled levels. Younger people benefit from tighter glycemic control as it may prevent strokes or heart attacks years down the road. Alternatively, older people may be more at risk of complications due to low sugar. Often, they are already taking several medications and additional treatment for glycemia may not be of benefit to them. The Canadian Diabetes Association’s most recent guidelines emphasized the need for individual glycemic goals for patients that account for their physical circumstances, health goals and values.

“We, as physicians, should be working with our younger people to help them manage their glycemic levels,” says Dr. Michelle Greiver, a Clinician Scientist at the Department of Family and Community Medicine, UTOPIAN’s Deputy Director, Scientist at North York General Hospital and co-lead for the study. “If you want to prevent blindness in 10 years, it is best to start by encouraging younger people to achieve tighter controls as they will live many more years with their condition.”

Good control of blood sugar reduces the onset of kidney disease and blindness at later stages of life and can potentially extend people’s lives. On the other hand, for the elderly, too much treatment provides limited benefits in healthily prolonging life.

“If blood sugar levels are too low for older people, they are at risk of fainting and falling which is particularly dangerous for the elderly — can break their hips if they fall,” says Dr. Greiver, “Older people sometimes cannot tell if their blood sugar is low. With excessive treatment, the risk of driving sugar levels too low is much greater.”

The problem was compounded when the patient, regardless of age, had one or more chronic medical conditions. The team observed that people with fewer chronic medical conditions had moderate glycemic control while those with more chronic diseases had tight glycemic controls. These results were inconsistent with the amended practice guidelines which recommend consideration of more moderate control when people had multiple chronic medical conditions.

Through 537 family physicians, researchers examined data from more than 30,000 Canadians across the country and spent two years uncovering the findings, a task Dr. Greiver says was arduous. She maintains that the results are fair, deserve further attention and could be, perhaps, an important step to improving the personalization of treatment for patients. She argues that patients should have the ability to set individualized targets with their primary care provider to ensure optimum care alongside their health circumstances.

Past guidelines recommended an HbA1c target of 7% (53 mmol/mol) or less for most patients.

The study is one aspect of a larger endeavour partnering the University of Toronto Practice-Based Research Network (UTOPIAN) and Diabetes Action Canada. The intent of this partnership is to create a data repository using information from primary care providers across the country that will help foster research to reduce diabetes complications and help people better manage their condition. Dr. Greiver states that this study is a "pulse-check" and can provide information for family doctors and their teams.

“This study is a stepping stone for more research,” says Greiver, “We cannot improve what we do not measure. We need to know how we are doing. We do not have to accept these results as we all know someone — a friend or a relative — struggling with diabetes. We want to ensure that we can help them achieve a healthier future.”

The BETTER Program Launches Two Research Studies for the Management of Chronic Diseases

When Dr. Eva Grunfeld designed the BETTER (Building on Existing Tools To Improve Chronic Disease Prevention and Screening in Primary Care) trial, she initially sought to improve prevention and screening for chronic diseases in primary care settings through the use of prevention practitioners. In the trial, which was co-led with Dr. Donna Manca, prevention practitioners were commonly nurses, nurse practitioners and dieticians who were trained to talk with patients about chronic disease screening and prevention. The trial was conducted in Toronto and Edmonton and involved almost 800 patients from 32 family physicians’ practices.

The study team developed several study aids in the form of evidence-based tools and toolkits and an algorithm for prevention practitioners on how to approach prevention and screening. The team also generated patient education and motivational interviewing tools to help these practitioners develop a personalized prevention prescription for each patient. The results of the trial showed that prevention practitioner intervention resulted in a significant improvement in the number of prevention actions each patient completed. There was also a trial, titled BETTER 2, which applied the key components from the BETTER trial in settings like Newfoundland and Labrador and the Northwest Territories.

There are two separate BETTER trials currently ongoing: DFCM investigators collaborated with principal investigators Dr. Lawrence Paszat (BETTER Health: Durham), and Dr. Donna Manca (BETTER WISE) to test the BETTER approach in various populations in BETTER Health: Durham and BETTER WISE. The purpose of both trials is to assess whether the results of the original BETTER trial can be reproduced in various settings with different populations and prevention practitioners.

BETTER Health: Durham Applies the BETTER Trial

Within the last two years, principal investigator Dr. Lawrence Paszat and co-principal investigators Drs. Aisha Lofters, Andrew Pinto and Mary Ann O’Brien have sought to determine if the BETTER approach could be adapted in a community setting like Durham Region, Ontario with a different population and prevention practitioners.

“We want to determine whether the BETTER approach could be extended outside of the primary care setting with other kinds of prevention practitioners in a randomized controlled trial,” says O’Brien. “Could it be as effective when delivered by trained public health nurses in a community setting? In particular, could the BETTER approach work for individuals between the ages of 40 and 64 who live in low-income neighbourhoods with low rates of cancer screening?”

Within this ongoing trial, The BETTER Health: Durham study will use community engagement strategies to assess if the BETTER approach will need to be adapted to meet the needs of community residents. The objective of the study is to evaluate if the BETTER approach is effective in helping participants improve chronic disease prevention and screening activities when trained public health nurses are the prevention practitioners. Participants will work with nurses to identify their goals for improving their health.

“The team is also partnering with Durham Region Health Department because they already had an initiative called “Health Neighbourhoods” which identified priority neighbourhoods, the same communities our trial wants to reach. Our public health partners also identified highly-skilled public health nurses who were already working in chronic disease prevention and screening. It’s a very good partnership.”

Although the research is currently underway, several process outcomes have materialized. So far, two nurses and other team members have received training as prevention practitioners and have shown great interest in seeing the project unfold. Investigators have been successful in putting together a Community Advisory Committee, comprising several community agencies in the Durham health and social services sectors, as part of the project goal. Two meetings have already taken place and a third planned for the fall. The committee has provided advice on recruiting members of the public for focus groups and interviews and on adapting the BETTER tools for a community setting.

“We have seen a great response from the community. They have been helpful in providing some guidance to the study team on how to approach the public for our focus groups. Once the study is finished and the results/outcomes have been determined, the team hopes to inform government and public health units in Ontario about next steps. We are looking forward to it.”

BETTER WISE Focuses on Cancer Patients

Another program applying the BETTER trial’s outcomes to a different population is the BETTER WISE Trial. The trial, which takes place in primary care settings in Alberta, Ontario and Newfoundland, tracks whether the approach can be useful for cancer survivors.

“Primary care providers tend to focus on survivorship but we can easily forget that the person who has outlasted cancer is still susceptible to other chronic diseases,” says Dr. Aisha Lofters. “We wanted to make sure that those patients receive a unique care plan and receive appropriate support.”

In this randomized trial, each patient has an individualized care plan with a prevention practitioner. There are four dedicated sites in Ontario: Markham Stouffville, Oak Med, North Shore and Marathon Family Health teams. Before the trial gets underway, the Better Wise team of researchers have been working on reviewing high-quality evidence about cancer and chronic disease prevention screening. Researchers have been actively updating the toolkit to specifically cater to patients living with cancer. Within the preliminary process of the programs’ roll-out, Lofters points to many silver linings in their recruitment process.

“We will be training three nurses and one dietitian using the BETTER framework, bringing a diverse group of stakeholders together.," she said. "More important, we have, at the same time, been reviewing the process and evidence about cancer screening and prevention from the previous trial in the hopes that the tools are applicable to our new group of patients.”

Ultimately, Drs. O’Brien and Lofters state that both trials will provide new knowledge about the BETTER approach and whether the findings of the original trial are similar to newer settings. Both trials have made a very big commitment to knowledge translation and plan to share the study results across Canada and internationally.

Dr. Aisha Lofters

Research From the CanIMPACT Team Highlighted in October Canadian Family Physician

Story published on October 17, 2016

When a patient is diagnosed with breast cancer, the prevailing assumption is that they leave their family physician and enter into the “black box” of cancer treatment centres.

As Dr. Eva Grunfeld writes in her commentary for this month’s Canadian Family Physician, however, this isn’t true. Many family physicians are willing and do play a greater role in the ongoing care of patients with breast cancer. While patients may have received their main treatment at a cancer centre almost exclusively in the past, research has shown that primary care is a “safe and acceptable alternative to cancer centre followup.”

In conjunction with Breast Cancer Awareness month and to recognize the role family physicians play in the diagnosis and treatment of breast cancer, Canadian Family Physician (CFP) is dedicating their October issue to the theme of breast cancer and the work of the Canadian Team to Improve Community-Based Cancer Care along the Continuum (CanIMPACT) research team. Led by Dr. Eva Grunfeld, Giblon Professor and Vice-Chair (Research) at DFCM, CanIMPACT is a multidisciplinary pan-Canadian group of primary care physicians, nurses, oncology specialist physicians, researchers, knowledge users and patients who are working to enhance the capacity of primary care to provide care to cancer patients and improve integration between primary care providers and cancer specialists.

The CanIMPACT team includes many DFCM faculty who have contributed to the articles published in the October issue of CFP issue. For instance, Drs. Heisey and Carroll co-author a practical guide for clinicians to assist in identifying and managing women with a family history of breast cancer. Drs. Carroll, O’Brien, Webster and Grunfeld are co-authors on an article on patient experiences with the cancer care continuum (lead author Dr. J. Easley). The findings show the main factor impacting patients’ experience is good communication with their health-care professionals, which contributes to a sense of well-co-ordinated care.

Dr. Carroll is also the lead author (with DFCM co-authors O’Brien, Heisey and Grunfeld) on a study of family physicians’ experiences with and perceptions of personalized genomic medicine in relation to cancer. Drs. Lofters, Moineddin and Grunfeld are co-authors (lead author Dr. L. Jiang) on a multi-province study using administrative health databases to examine family physician visits by breast cancer patients.

Dr. Grunfeld is please about the attention to the issue. “It has been inspiring to work with my DFCM colleagues and collaborators from across Canada and beyond in bringing this phase of the research to fruition,” she notes. “It is especially exciting to have the research published in a focused issue of CFP in recognition of Breast Cancer Awareness month.”